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Bangladesh Med J.

2015 Jan; 44 (1)

Original Article
Acute kidney injury is a common complication after acute stroke in
Mymensingh Medical College Hospital
Ray NC1, Chowdhury MAA2, Roy AS3, Muqueet MA4, Paul B5, Bhuiyan MMA6, Sarkar SR7
Abstract Introduction
Stroke represents a continuously evolving medical and social Stroke is represents a medical and social problem, being
problem, being the third leading cause of death after heart the third leading cause of death after heart disease and
disease and cancer in developed countries. Acute kidney cancer in developed countries.1 Annually 16.3 million
injury (AKI) may develop as a possible complication after people suffer from stroke worldwide, among which 11.2
acute stroke. Insufficient care of acute stroke patients is an million events occur in developing countries including
important factor behind it. It may be associated with a Bangladesh. About 5.8 million people die of stroke each
significant burden of morbidity and mortality. This cross year, the two third of which occurs in developing
sectional observational study was conducted in Mymensingh nations.2 The prevalence rates of stroke among South
Medical College & Hospital, Mymensingh from July 2012 to Asians living in India vary from 52 to 842 per 100,000
June 2014. A total of 240 patients with newly detected acute for all ages.3-5 Bangladesh is a small country in South
stroke confirmed by CT scan of brain were included in this Asia with high density of population (an average of 964
study. According to this study, 15.42% of acute stroke inhibitants / square kilometer).6 The prevalence of stroke
patients developed AKI. Majority (54.05%) of the AKI here is 3 per 1000 above the age of 40 years.7
patients were in >60 years age group. 17.93 % of male
patients developed AKI and 11.58% of female patients In the immediate period following a stroke, acute kidney
developed AKI. So, AKI was a common complication after injury (AKI) may develop as a possible complication.
acute stroke. Early diagnosis and management of AKI may be However, this association is frequently overlooked and
an important part of management of these stroke patients. underestimated in clinical trials.8 The brain and kidney
share a similar vascular structure with low-resistance
Key words: Acute Kidney Injury, stroke exposure of the small vessels to highly pulsatile flow and
pressure.9 As a result, microvascular damage to both
organs can lead not only to renal impairment with
reduced GFR but also to asymptomatic or symptomatic
1. *Dr Nitai Chandra Ray, Registrar brain infarcts and white matter lesions.10-13
Department of Nephrology, Mymensingh
Medical College Hospital, Mymensingh This cerebrorenal interaction is considered to be based on
small vessel disease. Because small vessel disease is a
2. Professor Dr Md Ayub Ali Chowdhury
systemic disorder, information about small vessel disease
Professor of Nephrology, National Institute of
in one organ may provide information on damage in
Kidney Diseases & Urology, Dhaka
another organ. Although mild AKI in most cases is
3. Dr Ashutosh Saha Roy, Assistant Professor “clinically” reversible, but in the tissue level, endothelial
Department of Nephrology, damage, tubular inflammation, and activation of
Mymensingh Medical College, Mymensingh intrarenal fibrotic pathways during kidney repair may
4. Dr Md Abdul Muqueet, Assistant Professor gradually damage kidney structure, leading to progressive
Department of Nephrology decline in renal function.13-16
Mymensingh Medical College, Mymensingh
5. Dr Binoy Paul, Assistant Professor, Department of The occurrence of AKI, defined by the RIFLE criteria, is
Gastroenterology, Chittagong Medical College, not a rare finding in stroke patients; more than one fourth
Chittagong of patients develop AKI in the first 2 days after the acute
6. Dr Mohammad Monzurul Alam Bhuiyan, Clinical stroke. The prevalence of AKI in acute stroke is 14.5%
Pathologist, SSMC & Mitford Hospital, Dhaka and the incidence of AKI and stroke 240 pmp/year. As
7. Dr Santana Rani Sarkar, Medical Officer expected, AKI develops more frequently in older persons.8
Department of Microbiology
Mymensingh Medical College. Mymensingh The purpose of the study was to find out the proportion
of acute kidney injury in patients with acute stroke in
*For correspondence Bnagladesh and to highlight the importance of serial

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Bangladesh Med J. 2015 Jan; 44 (1)

measurement of serum creatinine among the patients with hospital visit. All investigations were done in clinical
acute stroke, as a means to diagnosis of acute kidney pathology laboratory, biochemistry laboratory and
injury and management of these patients. radiology department of Mymensingh Medical College
Hospital. Patients were classified according to renal
Methods function using the serial serum creatinine levels. Data
This cross sectional observational study was conducted in were analysed according to standard statistical method
Department of Nephrology, Department of using computer based software.
Neuromedicine and Department of Medicine,
Mymensingh Medical College & Hospital (MMCH), Results
Mymensingh from July 2012 to June 2014. A total of 240 This study included 240 patients with acute stroke,
patients with acute stroke, admitted within 7 days of confirmed by CT scan of brain. Mean ± SD of age of
onset of symptoms and above 18 years of age, that AKI and non AKI patients were 65.59 ± 13.67 and 62.95
fulfilled the inclusion and exclusion criteria were included ± 13.89 years respectively. Amoong the AKI patients 26
in this study. A structured case record form was used (70.27%) were male and 11 (29.73%) were female.
which included detailed history, physical findings, results Among the non AKI patients 119 (58.62%) were male
of serial measurement of serum creatinine on admission, and 84 (41.38%) were female. Male: Female ratio among
on Day 2 & on Day 7, CT scan of brain and other AKI and non AKI patients were 2.36:1 and 1.42:1
relevant laboratory investigations. respectively. This sex ratio among the AKI and non AKI
patients was not significant. (Table-I)
The diagnosis of acute stroke was based on WHO
definition of stroke, with the support of convincing Among the AKI patients, Mean ± SD of time interval
history, compatiable clinical examnation finding and from onset of symptoms of stroke to hospital admission
confirmed by CT scan of brain. AKI was diagnosed by was 20.41 ± 15.67 hours, GCS was 9.89 ± 2.49, systolic
either an increase in serum creatinin by ≥ 0.3 mg/dl (≥ blood pressure was 163.24±19.41 mm of Hg, distolic
26.5 µmol/l) within 48 hours; or increase in serum blood pressure was 93.78 ± 12.33 mm of Hg and mean
creatinin to ≥1.5 time’s baseline, which was known to blood pressure was 116.94±13.34 mm of Hg (Table –I).
have occurred within the prior 7 days.17 As baseline Among the non AKI patients Mean ± SD of time interval
serum creatinine (before the present illness) was not from onset of symptoms of stroke to hospital admission
known in most of the cases, so serum creatinine level at was 23.50 ± 17.92 hours, GCS was 11.00 ± 1.92, systolic
admission was taken as baseline serum creatinine. blood pressure was 154.01±26.19 mm of Hg, distolic
blood pressure was 87.29 ± 12.55 mm of Hg and mean
Patients were evaluated meticulously with history, clinical blood pressure was 109.53±15.14 mm of Hg, respectively.
examination and necessary investigations at the time of (Table –I)

Table-I: Baseline characteristics of study patients according to AKI presence


Mean ± SD
Characteristics AKI Non AKI p value
(n=37) (n=203)
Age (Years) 65.59 ± 13.67 62.95 ± 13.89 0.2812
Male (n %) 26 (70.27) 119 (58.62) 0.0634
Female (n %) 11 (29.73) 84 (41.38) 0.0634
Time interval (from onset of
symptoms of stroke to hospital 20.41 ± 15.67 23.50 ± 17.92 0.2786
admission) hours.
GCS 9.89 ± 2.49 11.00 ± 1.92 0.0100
Systolic BP (mm of Hg) 163.24±19.41 154.01±26.19 0.0122
Diastolic BP (mm of Hg) 93.78 ± 12.33 87.29 ± 12.55 0.0033
Mean BP (mm of Hg) 116.94±13.34 109.53±15.14 0.0024

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Bangladesh Med J. 2015 Jan; 44 (1)

Among the AKI patients majority (54.05%) were in >60 among non-AKI patients majority (53.20%) were in >60
years age group. 40.54% were in 41-60 years age group years age group. 41.25% were in 41-60 years age group
and only 5.41% were in <40 years age group. Simillarly, and only 5.42% were in <40 years age group. (Table-II)

Table-II: Distribution of patients by age (n = 240)

Age (Years) AKI Non AKI Frequency

<40 2 (5.41) 11 (5.42) 13 (5.42)

41– 60 15 (40.54) 84 (41.38) 99 (41.25)


χ2=1.8269
P = 0.4011
>60 20 (54.05) 108 (53.20) 128 (53.33)

Total 37 (100.00) 203 (100.00) 240 (100.00)


* Figures within parentheses indicate percentage.

Out of 145 male patients, 26 (17.93%) patients Out of 240 acute stroke patients 37 patients developed
developed AKI, and out of 95 female patients 11 acute kidney injury (AKI) according to “KDIGO Clinical
(11.58%) patients developed AKI. Male female ratio of Practice Guideline, 2012” definition of AKI and
AKI was 1.55:1. This observed difference was not proportion of AKI was 15.42% among the acute stroke
significant. patients (Table III).

Table-III: Distribution of AKI in stroke according to sex (n=240)

Group AKI Non -AKI Frequency

Male 26 (17.93) 119 (82.07) 145 (100.00)


2
χ =3.446
Female 11 (11.58) 84 (88.42) 95 (100.00) OR= 1.66
P = 0.0634

Total 37 (15.42) 203 (84.58) 240 (100.00)

* Figures within parentheses indicate percentage.

Discussion 14.5% 8. This higher proportion of AKI observed in our


The present study was carried out to find the proportion study was due to lower GCS level and higher systolic,
of acute kidney injury as a possible complication in the distolic and mean blood pressure on admission among the
early period of acute stroke in Bangladesh and to highlight AKI patients in comparision to non AKI patients.
the importance of obtaining a base line serum creatinine
value early after admission for acute stroke and need for In another study, Tsagalis et al, 2009 found that 26.7% of
close monitoring of renal function during the acute stroke patients developed AKI. High incidence of
hospitalization or discharge. AKI in their study was due to the increased age (mean age
70.3 ± 11.9 yr), low baseline GFR, and the use of a
In this study, AKI developed in 15.42% of acute stroke high-sensitivity definition for the detection of AKI.
patients which was higher than the findings of the study Preexisting renal dysfunction was a major contributor to
of Covic et al 2008 in which the prevalence of AKI was the occurrence of AKI. In their study, only 13.4% of

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Bangladesh Med J. 2015 Jan; 44 (1)

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